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evolve and NCLEX Exam- Lower GI-Chapter 45 |Study Questions with 100% Correct Solutions
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evolve and NCLEX Exam- Lower GI-Chapter45 |Study Questions with 100% Correct
Solutions
A patient who is administering a bisacodyl (Dulcolax) suppository asks the nurse how long it will
take to work. The nurse replies that the patient will probably need to use the bedpan or
commode within which of the following time frames after administration?
A. 2-5 minutes
B. 15-60 minutes
C. 2-4 hours
D. 6-8 hours - ANSWER ANS: B. Bisacodyl (Dulcolax) suppositories usually are effective within
15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to
use the bedpan or commode
The nurse is caring for a patient in the emergency department with complaints of acute
abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower
abdominal quadrant, the patient complains of pain in the right lower quadrant. The nurse
will document this as which of the following diagnostic signs of appendicitis?
A. Rovsing sign
B. Referred pain
C. Chvostek's sign
,D. Rebound tenderness - ANSWER ANS: A. In patients with suspected appendicitis, Rovsing sign
may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower
quadrant.
The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and
vomiting. The patient has an abdominal mass and a bowel obstruction is suspected. The
nurse auscultating the abdomen listens for which of the following types of bowel sounds that
is consistent with the patient's clinical picture?
A. Low pitched and rumbling above the area of obstruction
B. High pitched and hypoactive below the area of obstruction
C. Low pitched and hyperactive below the area of obstruction
D. High pitched and hyperactive above the area of obstruction - ANSWER ANS: D. Early in
intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched,
sometimes referred to as "tinkling" above the level of the obstruction. This occurs because
peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes
complete, bowel sounds decrease and finally become absent.
The nurse is planning care for a 68-year-old patient with an abdominal mass and suspected
bowel obstruction. Which of the following factors in the patient's history increases the
patient's risk for colorectal cancer?
A. Osteoarthritis
B. History of rectal polyps
C. History of lactose intolerance
D. Use of herbs as dietary supplements - ANSWER ANS: B. A history of rectal polyps places this
patient at risk for colorectal cancer. This tissue can degenerate over time and become
malignant. The other factors identified do not pose additional risk to the patient.
The nurse is preparing to insert a nasogastric tube into a 68-year-old patient with an abdominal
mass and suspected bowel obstruction. The patient asks the nurse why this procedure is
necessary. Which of the following responses is most appropriate?
A. "The tube will help to drain the stomach contents and prevent further vomiting."
B. "The tube will push past the area that is blocked, and thus help to stop the vomiting."
, C. "The tube is just a standard procedure before many types of surgery to the abdomen."
D. "The tube will let us measure your stomach contents, so that we can plan what type of IV
fluid replacement would be best." - ANSWER ANS: A. The nasogastric tube is used to
decompress the stomach by draining stomach contents, and thereby prevent further vomiting.
A 61-year-old patient with suspected bowel obstruction has had a nasogastric tube inserted at
0400 hrs. The nurse shares in the morning report that the day shift staff should check the tube
for patency at which of the following times?
A. 0700 hrs, 1000 hrs, and 1300 hrs
B. 0800 hrs and 1200 hrs
C. 0900 hrs and 1500 hrs
D. 0900 hrs, 1200 hrs, and 1500 hrs - ANSWER ANS: B. A nasogastric tube should be checked
for patency routinely at four-hour intervals. Thus if the tube were inserted at 0400 hrs, it would
be due to be checked at 0800 hrs and 1200 hrs.
The nurse who inserted a nasogastric tube for a 68-year-old patient with suspected bowel
obstruction should write which of the following priority nursing diagnoses on the
patient's problem list?
A. Anxiety related to nasogastric tube placement
B. Abdominal pain related to nasogastric tube placement
C. Risk for deficient knowledge related to nasogastric tube placement
D. Altered oral mucous membrane related to nasogastric tube placement - ANSWER ANS: D.
With nasogastric tube placement, the patient is likely to breathe through the mouth and
may experience irritation in the affected nares. For this reason, the nurse should plan
preventive measures based on this nursing diagnosis.
A colectomy is scheduled for a 68-year-old woman with an abdominal mass, possible bowel
obstruction, and a history of rectal polyps. The nurse should plan to include which of the
following prescribed measures in the preoperative preparation of this patient?
A. Instruction on irrigating a colostomy
B. Administration of a cleansing enema
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